Figure 7: Patient 1 at the end of the operation. Plastic dressings cover the three trocar sites on the right side of the abdomen and the eight 2 mm stab incisions through which the transabdominal sutures were passed and then tied. The margins of the two hernia defects are marked with small x's. Two concentric ellipses encompass the two defects. The outer ellipse marks the 2-inch overlap of the mesh around the hernia defects.

Mentions: The pneumoperitoneum was reinsufflated. In Patient 1, the 12-mm trocar was removed. The rolled up mesh was inserted through the abdominal wall defect caused by the trocar's insertion. Once the mesh was inside of the abdomen, the 12-mm trocar was repositioned. In Patient 2, the mesh passed easily down the lumen of the 12-mm trocar. Using the 3-dimensional imaging system of da Vinci, the surgeon unrolled the mesh. During this part of the operation, a Cadiere grasper was used in the robot's right hand and a needle holder in the left. The labels were used to orient the mesh. The bedside assistant passed the tails of the sutures (Figure 5) through the abdominal wall one at a time with a laparoscopic suture passer (Karl Storz Endoscopy America, Santa Barbara, California). A 2-mm stab incision was made for each pair of suture tails. The pairs of tails were secured together with mosquito clamps. Once all sutures were passed through the abdominal wall, the pneumoperitoneum was deflated to about half of its pressure. The mesh was pulled up to the abdominal wall and the sutures were tied. The rim of the mesh between the sutures was secured to the abdominal wall with 5-mm surgical tacks (Autosuture ProTack, Autosuture, Norwalk, Connecticut). This ensured that bowel could not pass between the abdominal wall and mesh between the sutures (Figure 6). The pneumoperitoneum was deflated. The trocars were removed. The fascial defect of the 12-mm trocar was closed with 2 interrupted simple sutures of an absorbable suture. The skin incisions of the trocar sites were approximated with subcuticular sutures. Each wound was covered with an adhesive dressing (Figure 7). The orogastric tube, urinary catheter, and endotracheal tube were removed at the end of both operations.

Ballantyne GH, Hourmont K, Wasielewski A - JSLS (2003 Jan-Mar)

Bottom Line: Immersion of the surgeon within the 3-dimensional virtual operative field expedited each stage of these procedures.The articulation of the wristed telerobotic instruments greatly facilitated reaching the anterior abdominal cavity near the abdominal wall.This report indicates that telerobotic laparoscopic ventral hernia repair is feasible and suggests that telepresence technology facilitates this procedure.

Affiliation: Minimally Invasive & Telerobotic Surgery Institute, Hackensack University Medical Center, Hackensack, New Jersey 07601, USA. ghb@lapsurgery.com

Abstract: Laparoscopic ventral hernia repair shortens the length of hospital stay and achieves low rates of hernia recurrence. The inherent difficulties of performing advanced laparoscopy operations, however, have limited the adoption of this technique by many surgeons. We hypothesized that the virtual operative field and hand-like instruments of a telerobotic surgical system could overcome these limitations. We present herein the first 2 reported cases of telerobotic laparoscopic ventral hernia repair with mesh. The operations were accomplished with the da Vinci telerobotic surgical system. The hernia defects were repaired with dual-sided, expanded polytetrafluoroethylene (ePTFE) mesh. The mesh was secured in place with 8 sutures that were passed through the abdominal wall, and 5-mm surgical tacks were placed around the circumference of the mesh. The 2 operations were accomplished with total operative times of 120 and 135 minutes and total operating room times of 166 and 180 minutes, respectively. The patients were discharged home on postoperative days 1 and 4. The surgeon sat in an ergonomically comfortable position at a computer console that was remote from the patient. Immersion of the surgeon within the 3-dimensional virtual operative field expedited each stage of these procedures. The articulation of the wristed telerobotic instruments greatly facilitated reaching the anterior abdominal cavity near the abdominal wall. This report indicates that telerobotic laparoscopic ventral hernia repair is feasible and suggests that telepresence technology facilitates this procedure.